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Dental and Extraction Release Form

Save time during your next appointment! Complete your required dental and extraction release form online from any device at any time before your visit.

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Dental and Extraction Release Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. You can also download the form by clicking the button below.

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Name *

First

Last

Email *

Phone *

My pet is undergoing anesthesia today to have a dental cleaning and/or possible extraction(s). My pet has had a recent pre-surgical exam and my veterinarian has discussed the procedure with me and has given me a detailed treatment plan for review. *

The veterinarians at Mayfair Animal Hospital will do everything possible to preserve and maintain the health of your pet’s teeth. During the course of the examination and cleaning, loose or decayed teeth may be found. Unhealthy and decaying teeth can lead to further health complications for your pet including, but not limited to, heart disease. If, in the veterinarian’s professional judgment, these teeth should be removed do you give your consent?

Yes, I give my consent for the veterinarians to use their professional judgment and extract any teeth necessary to maintain my pet’s health. I agree that I will be responsible for any additional cost that may occur with the extractions that are necessary to keep my pet healthy.
Yes, I give my consent for extractions AFTER I have been called and informed of the situation. If I am NOT available, then I DO give my consent for the veterinarians to extract any teeth necessary.
Yes, I give my consent for extractions AFTER I have been called and informed of the situation. I agree if I am NOT available within 5 min of the veterinarian’s call, then the veterinarian will NOT proceed forward with extractions, and the patient will be awakened from anesthesia. I am aware that the veterinarian’s recommendation for extractions may result in my pet undergoing additional no teeth and being removed without verbal authorization from the owner.

All procedures involve some risk. We have provided many risk-reducing factors specific to the procedure, such as diagnostic blood testing, IV catheter with fluids, high-tech monitoring equipment, and a dedicated anesthetist. In the rare and unforeseen event of a life-threatening emergency, I understand that Mayfair Animal Hospital will initiate emergency measures and attempt to contact me immediately. I understand this may generate associated fees and that I will be responsible for these fees. *

I Accept
Declined

Emergency Measures

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Date *

Dental and Extraction Release Form

Dental and Extraction Release Form

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